During the course of our visit we spent time observing care and treatment on the in-patient ward and operating theatre.

We observed two people’s care and treatment from the ward through to their surgery and arrival in recovery. People were treated with the highest degree of care and sensitivity. They were managed safely prior to, during and following their procedures and staff were always mindful of maintaining people’s dignity.

We spoke with three people who used the service and one visiting relative on the ward. They all told us they were happy with the service they had received. They also told us that they had ‘received information about their procedures prior to their admission to the hospital.’

One person told us “My consultant is very good. I have seen them every day that I’ve been here. I have no complaints.” Another person told us “The nursing staff are great. I have been to the hospital before and they have remembered me. That means a lot, I couldn’t ask for better care.”

All of the people using the service that we spoke with told us their visitors had been able to visit at any time and they were always made to feel welcome by the staff on the ward.

We saw a range of information leaflets available in people’s bedrooms on the services available to them whilst in hospital and following discharge.

We spoke with three people who used the services and all were positive about the care and treatment they had received. They were complimentary about the staff and service provided. They told us they were involved in their care and treatment and information on the risks and benefits of their procedures were clearly explained throughout their care and treatment.

We spoke with four people receiving inpatient care and treatment and two people attending out patient appointments. All of the people we spoke with were positive about the care they received from staff at the hospital. They said that staff were caring and that they received good information and support in relation to their treatment.

Some of the things people told us were ‘Brilliant service everything was done on time a very positive experience’. 'Totally at ease and would recommend this hospital to others’. ‘Staff are courteous and treated me with respect’. I was in having my operation less than a month after seeing the Consultant’. Visitors can come whenever they want’. ‘The food is good and you get a choice, there are plenty of drinks all day long’. ‘If you press the buzzer staff come very quickly, even at night’. ‘I have no complaints’. ‘My consultant and doctor have been in to see me every day’.

People we spoke to were positive about the care they received from staff at the hospital. The said that staff were caring and that they received good information and support in relation to their treatment.

Some of the things people told us are:

'the care is very good, I could not imagine anything better'

'I couldn't be happier with the care I received.

The BMI Huddersfield hospital was owned by BMI Healthcare, a company which has a nationwide network of private hospitals. It provided surgery and inpatient treatment for NHS funded and private patients across a range of outpatient, diagnostic, and surgical services including cosmetic surgery, endoscopy, general surgery, cataract surgery and orthopaedic care. The building was built in the 1970’s and was originally used as a nursing home. It was acquired by BMI Healthcare in 2008. The hospital is registered with the CQC for 29 beds.

Facilities at the hospital included;

• An outpatients department and consulting rooms. There was a pre-assessment clinic located on Hanson wing. Diagnostic imaging facilities provided on site included an ultrasound scanner, and X-ray. There were two operating theatres where surgery, endoscopy and fluoroscopy were carried out. In-patient facilities were provided on Simpson ward.

The hospital had made the decision not to see any children in the outpatient department from January 2016 due to low numbers who had attended.

We inspected the hospital as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following two core services at the hospital; surgery and, outpatients and diagnostic imaging. We carried out the announced part of the inspection on 9 and 10 February 2016. We also carried out an unannounced visit on 18 February 2016.

Staff sent pathology tests twice a day via courier to an external off-site laboratory. Some pathology tests were performed on site at BMI Huddersfield using point of care testing equipment.

Referrals for outpatient consultations in orthopaedics, urology and ear, nose and throat (ENT) were seen at Oaklands health centre. We did not visit this location during the inspection. An MRI (magnetic resonance imaging) scanner unit was brought to the site once a week on a Saturday; we did not inspect that aspect of diagnostic services.

We rated the hospital as ‘requires improvement’ overall. Outpatients and diagnostic imaging services were rated as ‘requires improvement’, as were surgical services. For the hospital overall we rated the safe, effective, responsive and well led key questions as ‘requires improvement’. The caring key question was rated as ‘good’.

Are services safe at this hospital

We rated safety at the hospital as ‘requires improvement’ overall. We found;

There had been one ‘never event’ and one serious incident at the hospital during the reporting period. There had also been 246 clinical incidents during the same time reporting period from October 2014 to September 2015. We saw 56% of the incidents had an adverse outcome.

Most staff were aware of duty of candour and the need to be open and honest when things went wrong, although some outpatients staff had limited or no knowledge. The nominated person for the safeguarding of children and vulnerable adults was the director of clinical services. The interim executive director was also trained to the same level and staff could contact them for advice. Staff received mandatory training in safeguarding of vulnerable adults as part of their inductions and had two yearly safeguarding updates. Compliance for both adult and children safeguarding training was 100% across the hospital. Information provided to us by the hospital showed the safeguarding training module was out of date. Clinical areas were visibly clean; however a comprehensive infection prevention and control audit in March 2015 showed 38 areas of non-compliance were found. Some actions had been completed and some were still outstanding. There had been two deep joint surgical site infections reported in 2015.

Water safety was potentially unsafe due to action plans not being followed in a timely way. There were 47 risks on the risk register in relation to estates and facilities. Some risks had been on the register for almost three years without remedial action being taken. There were safety issues with external and internal aspects of the building which had not been acted upon at corporate level. The hospital did not directly employ any doctors. The two Resident Medical Officers (RMOs) were contracted to an external company. They worked a 24 hour - 7 day a week service on a rotational basis. During this time they were on site and available 24 hours a day. The consultant surgeons and anaesthetists had practising privileges. In October 2015 there were 76 doctors who had been approved to practice; all of these had more than 12 months service at the hospital. The RMO told us patient handovers took place to the other RMO at the end of the seven day period. RMOs also handed over patient care to consultants as needed. Medicines were stored safely. There had been previous incidents reported in relation to routine medicines and controlled drugs (CDs) covered by the misuse of drugs act. Arrangements were in place to transfer seriously ill patients to a local NHS hospital.

Are services effective at this hospital

We rated effectiveness as ‘requires improvement’ overall.

Effectiveness in outpatients and diagnostic imaging was inspected but not rated. We found;

The hospital took part in national and local audits; results were compared at a corporate level through the production of a monthly quality dashboard against other BMI hospitals and the NHS as a way of determining effectiveness in patient outcomes. Long term monitoring of patient outcomes was measured using Patient Reported Outcome Measures (PROMs), the National Joint Register programme and the Private Healthcare Information Network (PHIN). An enhanced recovery programme meant length of stay was shorter than average. Pain relief was effective and met patients’ needs in a timely way. There was positive multi-disciplinary working in the interest of patients and 24 hour medical cover from the resident medical officer. A corporate audit calendar enabled results to be aligned to improvement plans. Policies were mostly developed nationally but a number of the corporate policies were out of date. Staff did not always have the most up to date guidance to follow. There had been four unplanned readmissions within 29 days of discharge for the reporting period. This is low compared with other independent acute hospitals. 76 consultants had practising privileges to work at the hospital. All of these had more than 12 months service at the hospital. Practising privileges are when authority is granted to a doctor or dentist to provide patient care in the hospital by a hospital’s governing board. There was good practice in the use of association for peri-operative practice guidelines. Staff were allocated to theatre lists based on their skills and competencies. Consent forms had just 69% compliance in September 2015. Action plans to improve recording patient consent had begun to have improved results. Compliance figures for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training in the hospital was 95% in December 2015. All of the microwaveable meals in the ward fridge for patients were out of date by one day and no checks had been carried out on the ward freezer temperatures. The temperature gauge was broken and a new one had been ordered. However we did not see alternative arrangements in place to monitor the temperature or ensure the contents were kept at a safe temperature, while the gauge was broken. We found ice cream sorbet in the freezer which had been expired for three months.

Are services caring at this hospital

We rated caring at the hospital as ‘good’ overall. We found;

All patients we spoke with said they had been looked after with compassion and their dignity had been respected. An internal survey showed over 97% of patients were satisfied with the care they had received. The hospital scores in the friends and family test (FFT) averaged 85% for the reporting period. People understood the care and treatment choices available to them and were given appropriate information and support. Patients were supported to return to independence as soon as possible. We observed positive interaction between staff and patients. Staff gave patients information is a way they could understand and allowed time for questions. Patients and their families were able to be partners in their care. Phone calls were routinely made 48 hours after discharge to check patients were recovering and managing at home. During our inspection we heard only positive comments from patients.

Are services responsive at this hospital

We rated responsiveness at the hospital as ‘requires improvement’ overall. We found;

A high number of surgical procedures were cancelled due to lack of equipment or broken equipment, or a breakdown in pre assessment procedures. Some of the patient rooms and clinical areas were quite dated. Referral to treatment times (RTT) data for the reporting period had exceeded the target of 90% of admitted patients beginning treatment within 18 weeks. Reasonable adjustments had not been made to allow wheelchair users or patients with significant visual loss to use the inpatient facilities on an equal basis. There were no rooms on the ward which had been adapted for a physically disabled patient to use. The hospital reported that wheelchairs users would be accommodated on an individual basis with an assessment of their needs undertaken prior to admission. Toilets for wheelchair users were available in the outpatient department. Patient information leaflets were not available in other languages however translation services were available and staff knew how to access these. Sign language services were provided for those patients that needed them. The two theatres were used six days a week in order to support patient flow and reduce waiting times. Access and flow in the OPD and radiology departments was well managed. Dementia training was part of the corporate training programme for staff, but patients with advanced dementia were not treated at the hospital. If someone had advanced dementia or did not have capacity, they would be triaged against exclusion criteria on receipt of referral as the service was not designed to meet their needs. There had not been any complaints for the six months before our inspection and the number of complaints made about the hospital had decreased from 2014.

Are services well led at this hospital

We rated the well led key question as ‘requires improvement’ overall. We found;

The vision, values and clinical strategy were not well developed. They did not contain elements of compassion, dignity or equality. Staff were not aware of the overall vision or strategy for the hospital. The strategy action plan had not been updated since January 2015 and lacked having safety as a priority. The clinical governance committee fed into the Medical Advisory Committee (MAC). The hospital fed into the corporate governance arrangements via the hospital’s executive group. However, the governance framework and risk management approach did not always support the delivery of safe, good quality care. The governance, risk management and quality monitoring in outpatients required improvement. There was no audit programme in outpatients and audits carried out were unstructured with no action plans or follow up. A service level agreement (SLA) with an external company used to transfer patient notes to other sites, should have been reviewed every two years. It had not been updated since 2011. Governance in radiology was well established and there was an annual audit programme. We reviewed records during the inspection; over 80% of the World Health Organisation (WHO) safer surgery checklists had omissions. If preventable measures had been in place, the never event would not have occurred. There were repeated failures in equipment or a lack of equipment in theatre which resulted in procedures being cancelled after patients were anaesthetised. Incidents related to pre assessment were repeated over the course of a year and lessons apparently not learned. A recent change in leadership of pre assessment had been made. We reviewed the hospital risk register. Maintenance of the building and water safety did not appear to be a corporate priority. Some risks had been on the register for two to three years without full remedial action being taken despite being reported at a corporate level; for example, falling masonry, potholes in the drive, and the lack of fire doors in theatre. Water safety plans had not been acted upon in the required time. The senior managers had recently been in post and were aware of many of the issues. They had local improvement plans but were constrained by the corporate team. There was positive local leadership, the executive director, the ward manager and the director of clinical services were visible, approachable and accessible to staff. However, not all leaders had the necessary experience, or knowledge for aspects of their role. We found some staff had not been properly prepared or trained to take on certain roles such as carrying out root cause analysis (RCA) investigations. For example, managers carrying out root cause analysis (RCA) investigations had not received training in carrying these out. Staff told us they were happy and felt well supported in all of the services we visited. There was evidence of good team working, both within and between teams, and a positive open culture. The chartered society of physiotherapy (CSP) recognised the hospital’s physiotherapy team in their 2014 awards. This was related to the enhanced recovery programme for joint replacements. We saw evidence of good communication in the form of daily ‘comm cells’. These were meetings held between the hospital’s senior management team and the heads of department where patient admissions, staffing, risk and incidents were discussed. We also saw good practice in the form of safety ‘huddles’ taking place in theatres where surgeons discussed allergies and patient safety with all staff.

We saw several areas of outstanding practice including:

• We saw evidence of good communication in the form of daily ‘comm cells’. These were meetings held between the hospital’s senior management team and the heads of department where patient admissions, staffing, risk and incidents were discussed.
• We also saw good practice in the form of safety ‘huddles’ taking place in theatres where surgeons discussed allergies and patient safety with all staff.
• The chartered society of physiotherapy (CSP) recognised the hospital’s physiotherapy team in their 2014 awards. This was because of their involvement in the enhanced recovery programme for joint replacements. The average length of stay for both hip and knee replacements at the hospital was now below three days.
• We found the physiotherapy department had introduced the use of a quality of life questionnaire for all patients to monitor the effectiveness of treatment they gave to patients.
• The ward manager told us one of their objectives was to set up an ambulatory care centre which could be managed by skilled health care assistants. They said uncomplicated conditions could be treated without the need for an overnight stay in hospital.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• The hospital must ensure compliance with the WHO ‘five steps to safer surgery’ procedures.
• The hospital must ensure theatre equipment is safe, available and fit for purpose.
• The hospital must put processes in place to ensure there is a robust assessment in pre-assessment phase and a process must also be established so that action can be taken on investigation results from pre-assessment.
• The hospital must ensure infection control policies and procedures are followed and actions from the infection control and water safety plan are implemented.
• The hospital must ensure staff receive up to date safeguarding training relevant to their roles.
• The hospital must ensure the building management system has an alarm fitted so any unsafe changes in water temperature can be immediately detected.
• The hospital must ensure checks are in place and food served is within date; review delivery dates of food from external supplier.
• The hospital must ensure premises are safe and properly maintained. In particular, review lack of fire doors in theatre, fire doors in OPD, safe storage of waste in order to comply with legislation (HTM) 07-01), security of the medical gas storage area, and ward freezer checks for temperature.
• The hospital must ensure sufficient numbers of suitable competent staff in theatres and OPD, including allied health professionals.
• The hospital must ensure policies and procedures are reviewed and are in date.
• The hospital must ensure staff are suitably trained before carrying out root cause analysis investigations to optimise learning from adverse incidents.

In addition the provider should:

• The hospital should ensure there are clear systems in place with identified responsibilities for carrying out external quality assurance checks on point of care testing equipment.
• The hospital should review the position of the endoscope washer and review the route of trollies brought into theatres from the outside and through theatres.
• The hospital should consider using leaflets in other languages as well as in English.

Professor Sir Mike Richards

Chief Inspector of Hospitals